News flash! Yet another new cardiac study from yet another group of respected researchers has been published in yet another medical journal suggesting that (…wait for it!) women receive poorer care during a heart attack compared to our male counterparts.(1)
“We really don’t need yet another study that basically comes down to: ‘Sucks to be female. Better luck next life!’, do we?”
Well, Laura – apparently we do. Because those studies just keep on coming.
At what point, by the way, do agencies that issue grants to support cardiac research stop spending millions of dollars on “discovering” what Laura and I and countless other female heart attack survivors already know? I’ve been writing about research like this for years, and I’m quite frankly tired of continuing to cover the bleedin’ obvious.
One such study published in the New England Journal of Medicine, for example, found that women in their 50s and younger are seven times more likely to be misdiagnosed in mid-heart attack compared to men.(2) For real-life examples of these misdiagnoses, see: Stupid Things Cardiologists Say to Heart Patients
When will some gutsy cardiologist or Emergency Department head or med school out there finally be willing to actually step up to the plate to change the way medicine is practiced so that women who come into Emerg with cardiac symptoms are treated the way men are?
In this new study of 1,100 heart attack patients admitted to 24 hospitals in Canada, U.S. and Europe (median age: 50), Montréal researchers found that women experiencing heart attack are slower than men to have an EKG done, or to receive lifesaving clot-busting drugs, or to undergo artery-opening revascularization procedures.
The study’s authors posed this rationale to help explain why men receive faster appropriate treatments in Emergency compared to men:
“Clinical determinants of poorer access to care included anxiety, increased number of risk factors and absence of chest pain.”
In other words, researchers are suggesting that Emergency physicians are less likely to believe women are having a genuine cardiac event if patients seem anxious. The more anxious a woman appears to the Emergency physician, the harder it is to be taken seriously. This may be because doctors see lots of non-cardiac patients suffering with genuine anxiety who often present to Emergency with heart attack-like symptoms such as chest pain. Do docs simply get used to sending these patients home with a dismissive little “It’s not your heart” pat on the head?
But take it from me: few things in life are more anxiety-producing than being in the middle of a heart attack.
“There’s either something really wrong with you, or you’re just anxious.”
Secondly, physicians are less likely to believe women are having a genuine cardiac event if you have an increased number of risk factors. This may seem counter-intuitive: shouldn’t doctors be more suspicious of heart attack if they know you are actually at higher risk for heart attack?
But if you present with what doctors call co-morbidities like diabetes or high blood pressure, this study suggests that your cardiac issues may get lost in the shuffle.
Third, docs are less likely to believe women are having a genuine cardiac event if they are not having chest pain. But since up to 40% of women experience no chest symptoms at all during a heart attack, this leaves a whole whack of women at risk for not being taken seriously compared to patients who do have chest pain.(3)
I hasten to add here, however, that I was misdiagnosed with acid reflux and sent home from Emergency in mid-heart attack despite presenting with textbook heart attack symptoms of central chest pain, nausea, sweating and pain radiating down my left arm.
Even a simple consultation with Dr. Google at that time would have clearly confirmed the only possible correct diagnosis which was, of course, myocardial infarction (heart attack).
But the Montréal researchers offered up a most puzzling rationale for what they described as this “significant gender bias against women with heart disease”:
“Gender-related determinants included feminine traits of personality and responsibility for housework.”
The study participants were asked to complete a survey with questions about “feminine personality traits” (like being unassertive) and perceived social standing, as well as who in their household was responsible for “housework”.
Yes. You read that right.
The researchers’ take on the results: these feminine personality traits and housework habits (observed in both men and women in Emergency) are associated with inferior cardiac care.
Memo to Montréal researchers: since women still average 14 hours per week of unpaid domestic housework compared to men’s eight hours, it appears that asking subjects this question is a bit like asking: “Who wears a bra in your family?” – and then concluding that wearing a bra is associated with poor cardiac care.
What in God’s green earth was the purpose of including the housework question in the first place – unless it is to scare men off from pitching in around the house to ensure better care when they show up one day at Emerg?
And what are women supposed to do now with this housework theory?
There may indeed be a correlation between those feminine humans who do housework and their subsequent poor heart disease treatment. I’m not a scientist – but I was married to one for 20 years (does that count at all?) and here’s what I learned:
“Correlation does not equal causation.”
In other words, it’s also possible that subjects who experienced the gender bias shown in this study ate pickles on Tuesdays. So if we all stopped eating pickles on Tuesdays, would Emergency physicians start treating male and female heart patients equally? Now there’s a future research grant application for you . . .
Let’s consider the Montréal study’s results only, unembroidered by any fanciful theories of feminine traits or vacuuming skills.
“This is very significant. Gender bias is at play here.
“Women do wait longer than men for treatment – if they get diagnosed at all. There’s a saying about heart attacks: ‘Time is muscle’. The longer it takes to unblock a blocked coronary artery, the more heart muscle dies.
“We’re talking here about people under age 55 – in the prime of life. Delays in treatment can mean many, many years of living with a chronic disability that maybe could have been avoided.
“Emergency personnel like me tend to dismiss women who complain of chest pain as just being ‘anxious’. And since women are less likely to have chest pain than men during heart attack, we need to rewrite standard medical textbooks.
“It’s time to examine the appropriateness of the care given to younger heart patients, especially women.”
It’s what some in medicine call the “Yentl Syndrome”, as described by the late cardiologist Dr. Bernadine Healy who coined this phrase back in 1991, writing in The New England Journal of Medicine:
“Yentl, the 19th-century heroine of Isaac Bashevis Singer’s short story, had to disguise herself as a man to attend school and study the Talmud. Being ‘just like a man’ has historically been a price women have had to pay for equality.
“”It may therefore be sad, but not surprising, that women have all too often been treated less than equally in social relations, political endeavors, business, education, research, and in health care.”
This health care inequality includes cardiology.
An editorial in the same journal issue (again, remember that this was back in 1991) highlighted this discrimination against women in cardiology, including the reality that women hospitalized for coronary heart disease underwent both fewer major diagnostic and therapeutic procedures than men did.(4)
Meanwhile, how many more studies like the new Montréal paper do we need to read before this long-established gender gap in cardiac care is ultimately addressed?
January 31, 2016: The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be undertreated“, including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”
And finally, consider this story shared with me by a woman attending one of my heart health presentations. While lying on a gurney in the Emergency Department, she overheard this conversation between a physician and one of his (male) patients beyond the curtain separating her from the next bed. The doctor told the (male) patient:
“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.
So a male patient is thus kept in hospital for observation in spite of his ‘normal’ cardiac test results. But I and countless other females in mid-heart attack are being sent home from Emergency mistakenly diagnosed with indigestion or anxiety or menopause or a dog’s breakfast of many other misdiagnosis options available.
We know this gender bias is happening.
We don’t need yet another study to tell us so.
The real question now is when are those who have the power and the will to influence change going to start actually changing it?
Researchers, let me interrupt your grant funding applications and save you time and effort by telling you what you’re going to find out in any future studies you’re planning on gender bias in cardiology:
“Women heart patients are under-diagnosed and under-treated even when appropriately diagnosed compared to our male counterparts.”
Now can we start walking the talk to do something that finally addresses this disturbing reality?
(1) Pelletier R et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. 10.1503/cmaj.131450 CMAJ March 17, 2014 cmaj.131450.
(2) Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
(3) Canto JG, Rogers WJ, Goldberg RJ, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307(8):813-822.
(4) Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991;325:2221–5.
Q: What will it take to finally change the way women heart patients are diagnosed/treated?
- When Your “Significant EKG Changes” are Missed
- Yentl Syndrome: Cardiology’s Gender Gap is Alive and Well
- How Does It Really Feel to Have a Heart Attack? Women Survivors Tell Their Stories
- Diagnosis – and Misdiagnosis – of Women’s Heart Disease
- 14 Reasons To Be Glad You’re A Man When You’re Having a Heart Attack
- His and Hers Heart Attacks
- Heart Attack – or an Attack of Heartburn?
- Is it a Heart Attack – or a Panic Attack?
- What is Causing my Chest Pain?
- When Your Doctor Mislabels You As an “Anxious Female”
- Heart Disease: Not Just A Man’s Disease Anymore
- How Doctors Discovered That Women Have Heart Disease, Too
- Gender Differences in Heart Attack Treatment Contribute To Women’s Higher Death Rates
- How a Woman’s Heart Attack is Different From A Man’s